Pharmacology Exam 2023/2024 Updated Questions With Answers 100% Correctly Verified, Exams of Nursing

Download Pharmacology Exam 2023/2024 Updated Questions With Answers 100% Correctly Verified and more Exams Nursing in PDF only on Docsity! Pharmacology Exam 2023/2024 Updated Questions With Answers 100% Correctly Verified A 2-year-old child has chronic "toddler's" diarrhea, which has an unknown but benign etiology. The child's parent asks the primary care NP if a medication can be used to treat the child's symptoms. The NP should recommend giving: a. diphenoxylate (Lomotil). b. bismuth subsalicylate (Pepto-Bismol). c. attapulgite (Kaopectate). d. an electrolyte solution (Pedialyte). d. an electrolyte solution (Pedialyte). Antidiarrheals are not recommended in children. Opioids are contraindicated in children younger than 2 years. Bismuth and attapulgite are not recommended in children younger than 3 years of age. Oral rehydration with electrolyte solution is safe for young children. A 5-year-old child has chronic constipation. The primary care NP plans to prescribe a laxative for long-term management. In addition to pharmacologic therapy, the NP should also recommend____g of fiber per day. a.20 b. 15 c. 10 d. 25 c. 10 Each day a child should receive 1 g of fiber per year of age plus 5 g after 2 years of age. A 12-year-old patient has acute diarrhea and an upper respiratory infection. Other family members have had similar symptoms, which have resolved. The primary care NP should recommend: a. attapulgite (Kaopectate). b. bismuth subsalicylate (Pepto-Bismol). c. an electrolyte solution (Pedialyte). d. diphenoxylate (Lomotil). c. an electrolyte solution (Pedialyte). Antidiarrheals are not generally recommended in children. Bismuth is not recommended in children younger than 16 years of age with viral illnesses because it can mask symptoms of Reye's syndrome. Oral rehydration with electrolyte solution is safe. A 45-year-old patient who has a positive family history but no personal history of coronary artery disease is seen by the primary care NP for a physical examination. The patient has a body mass index of 27 and a blood pressure of 130/78 mm Hg. Laboratory tests reveal low-density lipoprotein, 110 mg/dL; high-density lipoprotein, 70 mg/dL; and triglycerides, 120 mg/dL. The patient does not smoke but has a sedentary lifestyle. The NP should recommend: a. 30 minutes of aerobic exercise daily. b. beginning therapy with a statin medication. c. taking 81 to 325 mg of aspirin daily. d. starting a thiazide diuretic to treat hypertension. a. 30 minutes of aerobic exercise daily. This patient is overweight but not obese, and blood lipids are within normal limits. Blood pressure is not elevated. Exercise is recommended as an initial risk reduction strategy because of its positive effects on blood pressure and blood lipids. Aspirin is generally given to patients older than 55 to 65 who are at risk. Statin medications and thiazide diuretics are not indicated. A 50-year-old patient who recently quit smoking reports a frequent morning cough productive of yellow sputum. A chest x- ray is clear, and the patient's FEV1 is 80% of predicted. Pulse oximetry reveals an oxygen saturation of 97%. The primary care NP auscultates clear breath sounds. The NP should: a.order a long-acting anticholinergic with albuterol twice daily. b. prescribe a moderate-dose ICS twice daily. c.prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed. d. reassure the patient that these symptoms will subside. c. prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed. For patients with stable COPD having respiratory symptoms with FEV1 between 60% and 80% of predicted, inhaled bronchodilators may be used. COPD is not reversible, and the symptoms will not subside. ICS therapy or long-acting anticholinergics are recommended when FEV1 is less than 60%. An 80-year-old patient with chronic stable angina has begun taking nadolol (Corgard) 20 mg once daily in addition to taking nitroglycerin as needed. After 1 week, the patient reports no change in frequency of nitroglycerin use. The primary care nurse practitioner (NP) should change the dose of nadolol to mg daily. a.20; twice b. 40; twice c.80; once d. 40; once d. 40; once b-Blockers are the treatment of choice for chronic stable and unstable angina. Their therapeutic effect is dose dependent, and drug titration should be based on frequency of angina symptoms and nitroglycerin use. Nadolol should be started at 20 mg daily for elderly patients when treating angina and should be increased by 20 mg every 3 to 7 days if symptoms do not improve. Nadolol is given once daily. An African-American patient is taking captopril (Capoten) 25 mg twice daily. When performing a physical examination, the primary care nurse practitioner (NP) learns that the patient continues to have blood pressure readings of 135/90 mm Hg. The NP should: a.change the drug to losartan (Cozaar) 50 mg once daily. b. increase the captopril dose to 50 mg twice daily. c.add a thiazide diuretic to this patient's regimen. d. recommend a low-sodium diet in addition to the medication c. add a thiazide diuretic to this patient's regimen. Some African-American patients do not appear to respond as well as whites in terms of blood pressure reduction. The addition of a low-dose thiazide diuretic often allows for efficacy in blood pressure lowering that is comparable with that seen in white patients. Increasing the captopril dose is not indicated. Losartan is an angiotensin receptor blocker (ARB) and is not indicated in this case. An African-American patient who is obese has persistent blood pressure readings greater than 150/95 mm Hg despite treatment with a thiazide diuretic. The primary care NP should consider prescribing a(n): a. b-blocker. b. angiotensin receptor blocker. c. ACE inhibitor. d. calcium channel blocker. d. calcium channel blocker. African-American patients are considered good candidates for calcium channel blockers to treat hypertension. Treatment with calcium channel blockers as monotherapy in African- American patients has proved to be more effective than some other classes of antihypertensive agents. A child with chronic allergic symptoms uses an intranasal steroid for control of symptoms. At this child's annual well-child checkup, the NP should carefully review this child's: a. height and weight. b.blood pressure. c. liver function tests. d.urinalysis. a. height and weight. Intranasal corticosteroids can cause growth suppression in children. When using intranasal steroids in children, the lowest dosage should be used for the shortest period of time necessary, and growth should be routinely monitored. It is not necessary to evaluate urine, blood pressure, or liver function because of intranasal steroid use. A female patient who is underweight tells the primary care NP that she has been using bisacodyl (Dulcolax) daily for several years. The NP should: a. counsel the patient to discontinue the laxative and increase fluid and fiber intake. b. tell her that long-term use of suppositories is safer than long- term laxative use. c. suggest she use polyethylene glycol (MiraLAX) on a daily basis instead. d. prescribe docusate sodium (Colace) and decrease bisacodyl gradually. d. prescribe docusate sodium (Colace) and decrease bisacodyl gradually. Patients who abuse laxatives are at risk for cathartic colon and for electrolyte imbalances. These patients should be weaned from their stimulant laxative and placed on safer long-term laxatives, such as a bulk laxative or stool softener. Polyethylene glycol is a stimulant. Long-term use of suppositories causes rectal irritation. Discontinuing the laxative without a long-term laxative will lead to rebound constipation. An NP prescribes azelastine for a patient who has allergic rhinitis. The NP will teach the patient that this drug: a. will cause rebound congestion if withdrawn suddenly. b. can cause many systemic side effects such as drowsiness. c. will not provide maximum relief for a few weeks. d. may cause a bitter aftertaste. d. may cause a bitter aftertaste Azelastine is a topical antihistamine with few adverse systemic side effects. Patients may experience relief from symptoms within 30 minutes. Decongestants can cause rebound congestion if withdrawn suddenly. Topical antihistamines rarely cause systemic side effects. An NP sees a patient who reports persistent seasonal symptoms of rhinorrhea, sneezing, and nasal itching every spring unrelieved with diphenhydramine (Benadryl). The NP should prescribe: a. triamcinolone (Nasacort AQ). b. cromolyn sodium (Nasalcrom). c. azelastine (Astelin). d. phenylephrine (Neo-Synephrine) a. triamcinolone (Nasacort AQ) According to randomized controlled trials in patients with allergic rhinitis, oral antihistamines are used first to help control itching, sneezing, rhinorrhea, and stuffiness in most patients. Intranasal corticosteroids are indicated for patients who do not respond to antihistamines. Azelastine is a topical antihistamine. Phenylephrine is a decongestant, and this patient does not have congestion. Cromolyn sodium is less effective than intranasal corticosteroids. A parent asks an NP which over-the-counter medication would be best to give to a 5-year-old child who has a viral respiratory illness with nasal congestion and a cough. The NP should recommend which of the following? a.Increased fluids with a teaspoon of honey b. An antitussive/expectorant combination such as Robitussin DM c.Diphenhydramine (Benadryl) d. Over-the-counter pseudoephedrine with guaifenesin (Sudafed) a. Increased fluids with a teaspoon of honey Nonpharmacologic treatments are recommended for children younger than 6 years. Adequate hydration can decrease cough, thin secretions, and hydrate tissues. A teaspoon of honey has been shown to be effective in reducing cough in small children. Diphenhydramine is an antihistamine that dries nasal secretions but does not aid in decongestion. Sudafed and Robitussin are not recommended in children younger than 6 years. A patient asks an NP about using an oral over-the-counter decongestant medication for nasal congestion associated with a viral upper respiratory illness. The NP learns that this patient uses loratadine (Claritin), a b-adrenergic blocker, and an intranasal corticosteroid. The NP would be concerned about which adverse effects? a.Rebound congestion b. Liver toxicity c.Excessive drowsiness d. Tremor, restlessness, and insomnia d. Tremor, restlessness, and insomnia b-Adrenergic blockers and monoamine oxidase inhibitors may potentiate the effects of decongestants, such as tremor, restlessness, and insomnia. Liver toxicity, excessive drowsiness, and rebound congestion are not known adverse effects of drug interactions. A patient comes to the clinic with a 3-day history of fever and a severe cough that interferes with sleep. The patient asks the NP about using a cough suppressant to help with sleep. The NP should: a.suggest that the patient try a guaifenesin-only over- the- counter product. b. prescribe an antibiotic to treat the underlying cause of the patient's cough. c.order a narcotic antitussive to suppress cough. d. obtain a thorough history of the patient's symptoms. d. obtain a thorough history of the patient's symptoms. It is important to determine the underlying disorder that is causing the cough to rule out serious causes of cough. The NP should obtain a thorough history before prescribing any treatment. A narcotic antitussive may be used after serious causes are ruled out. Guaifenesin may be used to make nonproductive coughs more productive. Antibiotics are indicated only for a proven bacterial infection. A patient comes to the clinic with a 4-day history of 10 to 12 liquid stools each day. The patient reports seeing blood and mucus in the stools. The patient has had nausea but no vomiting. The primary care NP notes a temperature of 37.9° C, a heart rate of 96 beats per minute, and a blood pressure of 90/60 mm Hg. A physical examination reveals dry oral mucous membranes and capillary refill of 4 seconds. The NP's priority should be to: a. administer opioid antidiarrheal medications. b. obtain stool cultures. c. consider prescribing metronidazole. d. begin rehydration therapy. d. begin rehydration therapy. Acute diarrhea is usually mild and self-limited. Nonpharmacologic measures, especially bowel rest and adequate hydration, are helpful and should be a priority. Stool cultures may be ordered after hydration therapy is begun. Metronidazole is indicated if C. difficile is present. Opioid antidiarrheals may prolong symptoms. A patient comes to the clinic with a complaint of gradual onset of left-sided weakness. The primary care NP notes slurring of the patient's speech. A family member accompanying the patient tells the NP that these symptoms began 4 or 5 hours ago. The NP will activate the emergency medical system and expect to administer: a.warfarin (Coumadin) and aspirin. b. 325 mg of chewable aspirin. c.LMWH. d. intravenous alteplase and aspirin. b. 325 mg of chewable aspirin. Alteplase is used to treat ischemic stroke but is contraindicated if onset of symptoms occurred 3 hours previously. The administration of anticoagulation or antiplatelet agents during the first 24 hours is not recommended. The oral administration of aspirin within 24 to 48 hours after stroke onset is recommended. A patient comes to the clinic with a history of syncope and weakness for 2 to 3 days. The primary care NP notes thready, rapid pulses and 3- second capillary refill. An ECG reveals a heart rate of 198 beats per minute with a regular rhythm. The NP should: a. order digoxin and verapamil and ask the patient to return for a follow- up examination in 1 week. b. administer intravenous fluids and obtain serum electrolytes. c. send the patient to an emergency department for evaluation and treatment. d. administer amiodarone in the clinic and observe closely for response. c. send the patient to an emergency department for evaluation and treatment. Paroxysmal supraventricular tachycardia (PSVT) is a very fast regular rate and rhythm. This patient is becoming decompensated and should be referred to the emergency department for evaluation and treatment. The primary care NP should not treat this in the clinic or as an outpatient until the patient is stable. A patient comes to the clinic with a recent onset of nocturnal and exertional dyspnea. The primary care nurse practitioner (NP) auscultates S3 heart sounds but does not palpate hepatomegaly. The patient has mild peripheral edema of the ankles. The NP should consult a cardiologist to discuss prescribing a(n): a.b-blocker. b. angiotensin receptor blocker (ARB). c.loop diuretic. d. angiotensin-converting enzyme (ACE) inhibitor. c. loop diuretic. This patient shows signs of systolic heart failure. Treatment for heart failure should begin with a loop diuretic, with an ACE inhibitor added after the diuretic has been taken. b-Blockers are used in patients with minimal fluid retention and would be added later. ARBs are used if ACE inhibitors are not tolerated or are ineffective. A patient has been diagnosed with IBS and tells the primary care NP that symptoms of diarrhea and cramping are worsening. The patient asks about possible drug therapy to treat the symptoms. The NP should prescribe: a. dicyclomine (Bentyl). b. simethicone (Phazyme). c. metoclopramide (Reglan). d. mesalamine (Asacol). a. dicyclomine (Bentyl). Dicyclomine has indirect and direct effects on the smooth muscle of the gastrointestinal (GI) tract. Both actions help to relieve smooth muscle spasm. Mesalamine is used to treat ulcerative colitis. Simethicone acts locally to treat symptoms of trapped air and gas. Metoclopramide is used to increase motility. A patient is in the clinic for an annual physical examination. The primary care NP obtains a medication history and learns that the patient is taking a b-blocker and nitroglycerin. The NP orders laboratory tests, performs a physical examination, and performs a review of systems. Which finding may warrant discontinuation of the b-blocker in this patient? a.Decreased exercise tolerance b. Nausea, vomiting, and anorexia c.Wheezing, dyspnea, and cough d. Increased triglycerides c. Wheezing, dyspnea, and cough b-Blockers may cause bronchospasm in susceptible patients, and discontinuation of the b- blocker may be required. b-Blockers may cause an insignificant increase in serum triglycerides. Exercise intolerance, fatigue, and gastrointestinal side effects are common. A patient is taking a low-dose PPI for long-term management of GERD and reports taking sodium bicarbonate (Alka-Seltzer) to help with occasional heartburn. The primary care NP should tell the patient to: a.take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer). b. change to aluminum hydroxide (Amphojel). c.use magnesium hydroxide (Milk of Magnesia) instead. d. continue using sodium bicarbonate (Alka-Seltzer) as needed. a. take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer). Sodium bicarbonate is not suitable for long-term use because of side effects. Calcium carbonate requires monitoring when used long-term but has the highest acid-neutralizing capacity. Antacids containing aluminum and magnesium can cause electrolyte imbalances. A patient reports having episodes of dizziness, nausea, and lightheadedness and describes a sensation of the room spinning when these occur. The primary care NP will refer the patient to a specialist who, after diagnostic testing, is likely to prescribe: a.ondansetron. b. scopolamine. c. meclizine. d. dimenhydrinate. c. meclizine. Patients with vertigo may experience whirling or a feeling of the room spinning around. In true vertigo, the patient can identify the direction in which the room is spinning. Anticholinergics are the most effective agents in cases of motion sickness or vertigo. Meclizine has a specific indication to treat vertigo. A patient reports having occasional acute constipation with large, hard stools and pain and asks the primary care NP about medication to treat this condition. The NP learns that the patient drinks 1500 mL of water daily; eats fruits, vegetables, and bran; and exercises regularly. The NP should recommend: a. a daily bulk laxative. b. glycerin suppositories as needed. c. a saline laxative as needed. d. long-term docusate sodium. c. a saline laxative as needed. Mild short-term constipation may be treated with a saline laxative or a bulk laxative as needed. Daily laxatives are not recommended. Glycerin suppositories can cause irritation of the rectum with long-term use. A patient takes an antispasmodic and an occasional antidiarrheal medication to treat IBS. The patient comes to the clinic and reports having dry mouth, difficulty urinating, and more frequent constipation. The primary care NP notes a heart rate of 92 beats per minute. The NP should: a. discontinue the antidiarrheal medication. b. encourage the patient to increase water intake. c. lower the dose of the antispasmodic medication. d. prescribe a TCA. c. lower the dose of the antispasmodic medication. Patients taking antispasmodic medications should be monitored for anticholinergic side effects, such as increased heart rate, dry mouth, difficulty urinating, and constipation. The NP should lower the dose if needed. TCAs are used to treat pain long-term. Because the antidiarrheal medication is used as needed, there is no reason to discontinue it. Increasing water intake may improve symptoms associated with side effects but would not treat the underlying cause of these symptoms. A patient tells a nurse practitioner (NP) that several coworkers have upper respiratory infections and asks about the best way to avoid getting sick. The NP should recommend which of the following? a. Zinc gluconate supplements b. Frequent hand washing c.Echinacea d. Normal saline nasal irrigation B. Frequent hand washing. Hand washing is the most effective way to prevent the spread of viral upper respiratory illness (VURI). Echinacea has not been shown to be effective in preventing VURI. Zinc gluconate may decrease the duration of a VURI if taken within 24 hours of onset, but it does not prevent infection. Normal saline irrigation is helpful for symptomatic relief after a VURI has begun. A patient undergoes a routine electrocardiogram (ECG), which reveals occasional premature ventricular contractions that are present when the patient is resting and disappear with exercise. The patient has no previous history of cardiovascular disease, and the cardiovascular examination is normal. The primary care NP should: a.prescribe quinidine (Quinidex Extentabs). b. consider using amiodarone if the patient develops other symptoms. c.refer the patient to a cardiologist for further evaluation. d. tell the patient that treatment is not indicated d. tell the patient that treatment is not indicated. The most important factor in determining whether to treat premature ventricular contractions is the presence of underlying heart disease, such as myocardial ischemia, previous myocardial infarction, cardiac scarring or hypertrophy, or left ventricular dysfunction. Because of the risks associated with antiarrhythmic therapy, patients should not be treated unless clear indications are present. Premature ventricular contractions are not treated if the patient is asymptomatic, if the patient has a normal heart, if the premature ventricular contractions are simple, and if they disappear with exercise. Amiodarone is not used to treat acute premature ventricular contractions but is used for long-term prophylaxis. A patient undergoes endoscopy, and a diagnosis of erosive esophagitis is made. The patient does not have health insurance and asks the primary care NP about using OTC antacids such as Tums. The NP should tell the patient that Tums: a.neutralize stomach acid as well as proton pump inhibitors (PPIs) b. do not help reduce symptoms of erosive esophagitis. c.can help to heal erosions in esophageal tissue. d. help reduce symptoms in conjunction with PPIs. d. help reduce symptoms in conjunction with PPIs. Antacids reduce symptoms but do not have a significant effect on healing of erosions or esophagitis. If the patient has severe symptoms, has found treatment for milder symptoms to be ineffective, or has experienced erosion that is documented by endoscopy, he or she should be started on a PPI. A patient who has a history of angina has sublingual nitroglycerin tablets to use as needed. The primary care nurse practitioner (NP) reviews this medication with the patient at the patient's annual physical examination. Which statement by the patient indicates understanding of the medication? a. "I should take 3 nitroglycerin tablets 5 minutes apart and then call 9- 1- 1." b. "I should call 9-1-1 if chest pain persists 5 minutes after the first dose." c. "I should take nitroglycerin and then rest for 15 minutes before taking the next dose." d. "I should take aspirin along with the nitroglycerin when I have chest pain." b. "I should call 9-1-1 if chest pain persists 5 minutes after the first dose." Although the traditional recommendation is for patients to take up to 3 nitroglycerin doses over 15 minutes before accessing emergency medical services (EMS), more recent guidelines suggest an alternative strategy to reduce delays in emergency care. These include instructions to call 9-1-1 immediately if pain persists for 5 minutes after the first dose. Aspirin is recommended when the patient is being transported to emergency care and is not recommended as an adjunct to nitroglycerin with each episode of chest pain. The three doses of nitroglycerin are given 5 minutes apart over 15 minutes. A patient who has a history of chronic constipation uses a bulk laxative to prevent episodes of acute constipation. The patient reports having an increased frequency of episodes. The primary care NP should recommend: a.adding docusate sodium (Colace). b. polyethylene glycol (MiraLAX) and bisacodyl (Dulcolax). c.adding nonpharmacologic measures such as biofeedback. d. lactulose (Chronulac) and polyethylene glycol (MiraLAX). a. adding docusate sodium (Colace). Patients treated for long-term constipation should begin with a bulk laxative. If that is not effective, the addition of a second laxative may be necessary. Using two laxatives from the same category is not recommended. A stool softener, such as docusate sodium, is appropriate. Bisacodyl is not a second-line treatment. Lactulose and polyethylene glycol are from the same category. A patient who has angina is taking nitroglycerin and long- acting nifedipine. The primary care NP notes a persistent blood pressure of 90/60 mm Hg at several follow-up visits. The patient reports lightheadedness associated with standing up. The NP should consult with the patient's cardiologist about changing the medication to: a.amlodipine (Norvasc). b. verapamil HCl (Calan). c.isradipine (DynaCirc). d. short-acting nifedipine (Procardia). b. verapamil HCl (Calan). Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related drugs, such as isradipine and amlodipine. A patient who has angina uses 0.4 mg of sublingual nitroglycerin for angina episodes. The patient brings a log of angina episodes to an annual physical examination. The primary care NP notes that the patient has experienced an increase in frequency of episodes in the past month but no increase in duration or severity of pain. The NP should: a. increase the nitroglycerin dose to 0.6 mg per dose. b. contact the patient's cardiologist to discuss admission to the hospital. c. change from a sublingual to a transdermal patch nitroglycerin. d. discontinue the nitroglycerin and order ranolazine (Ranexa ER). b. contact the patient's cardiologist to discuss admission to the hospital. Unstable angina is a change in pattern or pain, such as an increase in frequency, severity, or duration of pain and fewer precipitating factors. Patients with unstable angina should be admitted to a coronary care unit. The primary care NP should not change any medications without consultation with the patient's cardiologist. A patient who has atrial fibrillation (AF) has been taking warfarin (Coumadin). The primary care nurse practitioner (NP) plans to change the patient's medication to dabigatran (Pradaxa). To do this safely, the NP should: a.start dabigatran 7 to 14 days after discontinuing warfarin. b. begin giving dabigatran 1 week before discontinuing warfarin. c.order frequent monitoring of the patient's INR after dabigatran therapy begins. d. initiate dabigatran when the patient's international normalized ratio (INR) is less than 2. d. initiate dabigatran when the patient's international normalized ratio (INR) is less than 2. There are no requirements for monitoring the INR or other measures for patients taking dabigatran. When changing from warfarin, it is recommended that dabigatran be initiated when the INR is less than 2. A patient who has been taking digoxin 0.25 mg daily for 6 months reports that it is not working as well as it did initially. The primary care NP should: a. contact the patient's pharmacy to ask if generic digoxin was dispensed. b. recommend a reduced potassium intake. c. hold the next dose of digoxin and obtain a serum digoxin level. d. increase the dose of digoxin to 0.5 mg daily. a. contact the patient's pharmacy to ask if generic digoxin was dispensed Clinicians should be aware that generic digoxin marketed by different companies may not be bioequivalent to the branded digoxin (Lanoxin). Patients with hyperkalemia would show intensified effects, not diminished effects of digoxin. Patients with diminished effects may have received a generic brand. It is not correct to increase the dose of digoxin without first obtaining a digoxin level. Because this patient is reporting decreased effects, it is unnecessary to suspect toxicity. A patient who has been taking propranolol for 6 months reports having nocturnal cough and shortness of breath. The primary care NP should: a.obtain serum drug levels to monitor for toxicity of this medication. b. contact the patient's cardiologist to discuss changing to a selective b-blocker. c.instruct the patient to increase activity and exercise to counter these side effects. d. tell the patient to stop taking the medication. b. contact the patient's cardiologist to discuss changing to a selective b-blocker. Nocturnal cough and shortness of breath may be a side effect of propranolol, which can cause bronchospasm because it is a nonselective â-blocker. The NP should discuss a selective b- blocker with the patient's cardiologist. â-Blockers should never be stopped abruptly. Bradycardia and hypotension are signs of toxicity. Increasing activity would not counter these side effects if bronchospasm is the cause. A patient who has had a previous myocardial infarction has a blood pressure of 135/82 mm Hg. The patient's body mass index is 28, and the patient has a fasting plasma glucose of 105 mg/dL. The primary care NP should prescribe: a. a calcium-channel blocker. b. a thiazide diuretic. c. lifestyle modifications. d. an angiotensin-converting enzyme inhibitor. d. an angiotensin-converting enzyme inhibitor. This patient has prehypertension but has a compelling reason for treatment. Patients who have had a myocardial infarction should be treated with a b-blocker and angiotensin- converting enzyme inhibitor or angiotensin II receptor blocker (ARB). A patient who has had four to five liquid stools per day for 4 days is seen by the primary care NP. The patient asks about medications to stop the diarrhea. The NP tells the patient that antidiarrheal medications are: a.useful in cases of acute infection with elevated temperature. b. useful when other symptoms, such as hematochezia, develop. c. not curative and may prolong the illness. d. most beneficial when symptoms persist longer than 2 weeks. c. not curative and may prolong the illness. Treatment of patients with acute diarrhea with antidiarrheals can prolong infection and should be avoided if possible. Antidiarrheals are best used in patients with mild to moderate diarrhea and are used for comfort and not cure. They should not be used for patients with bloody diarrhea or high fever because they can worsen the disease. Prolonged diarrhea can indicate a more serious cause, and antidiarrheals should not be used in those cases. A patient who has heart failure has been treated with furosemide and an ACE inhibitor. The patient's cardiologist has added digoxin to the patient's medication regimen. The primary care NP who cares for this patient should expect to monitor: a. blood glucose levels. b. complete blood counts (CBCs). c. serum electrolytes. d. serum thyroid levels. c. serum electrolytes. Hypokalemia makes the myocardium more sensitive to digoxin. These levels should be monitored closely in patients taking furosemide, which can deplete potassium. Serum glucose, thyroid levels, and a CBC should be monitored if indicated by other conditions. A patient who has hyperlipidemia has been taking atorvastatin (Lipitor) 60 mg daily for 6 months. The patient's initial lipid profile showed LDL of 180 mg/dL, HDL of 45 mg/dL, and triglycerides of 160 mg/dL. The primary care NP orders a lipid profile today that shows LDL of 105 mg/dL, HDL of 50 mg/dL, and triglycerides of 120 mg/dL. The patient reports muscle pain and weakness. The NP should: a. order a creatine kinase-MM (CK-MM) level. b. change atorvastatin to twice-daily dosing. c. order liver function tests (LFTs). d. add gemfibrozil (Lopid) to the patient's medication regimen. a. order a creatine kinase-MM (CK-MM) level. Hepatotoxicity and muscle toxicity are the two primary adverse effects of greatest concern with statin use. Patients who report muscle discomfort or weakness should have a CK-MM level drawn. LFTs are indicated with signs of hepatotoxicity. It is not correct to change the dosing schedule. Gemfibrozil is not indicated. A patient who has IBS experiences diarrhea, bloating, and pain but does not want to take medication. The primary care NP should recommend: a.avoiding gluten and lactose in the diet. b. beginning aerobic exercise, such as running, every day. c.increasing water intake to eight to ten glasses per day. d. 25 g of fiber each day. d. 25 g of fiber each day. A diet with adequate fiber is the cornerstone of treatment, and 25 g per day is recommended. Unless the patient has a documented gluten or lactose malabsorption, avoiding these substances is not recommended. Water intake should be six to eight glasses per day. Regular walking is usually the best exercise. A patient who has IBS has been taking dicyclomine and reports decreased pain and diarrhea but is now having occasional constipation. The primary care NP should recommend: a.beginning therapy with a TCA. b. beginning treatment with an SSRI. c.increasing the amounts of raw fruits and vegetables in the diet. d. over-the-counter (OTC) laxatives as needed when constipated. d. over-the-counter (OTC) laxatives as needed when constipated. Patients who experience constipation may use OTC laxatives as needed. Antidepressants, such as SSRIs or TCAs, are used long-term to help with pain. Raw fruits and vegetables can increase the likelihood of bloating. A patient who has migraine headaches has begun taking timolol and 2 months after beginning this therapy reports no change in frequency of migraines. The patient's current dose is 30 mg once daily. The primary care NP should: a.tell the patient to continue taking the timolol and return in 1 month. b. obtain serum drug levels to see if the dose is therapeutic. c.change the medication to propranolol. d. increase the dose to 40 mg once daily. a. tell the patient to continue taking the timolol and return in 1 month. When giving timolol for migraine prophylaxis, the provider should inform the patient that it may take several weeks for therapy to be effective. The dose should be titrated and maintained for a minimum of 3 months before the treatment is deemed a failure. It may be necessary to change to propranolol if the therapy is not effective in 1 month. The maximum dose of timolol for migraine prophylaxis is 30 mg. Drug effectiveness is determined by patient response, not serum drug levels. A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues to have LDL cholesterol of 140 mg/dL after 3 months of therapy. The primary care NP increases the dose from 10 mg daily to 20 mg daily. The patient reports headache and dizziness a few weeks after the dose increase. The NP should: a.change the patient's medication to cholestyramine (Questran). b. add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily. c.change the atorvastatin dose to 15 mg twice daily. d. recommend supplements of omega-3 along with the atorvastatin. b. add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily. When used in combination with a low-dose statin, ezetimibe has been noted to produce an additional 18% reduction in LDL. Because this patient continues to have elevated LDL along with side effects of the statin, the NP should resume the lower dose of the statin and add ezetimibe. Atorvastatin is given once daily. Cholestyramine and omega-3 supplements are not indicated. A patient who has severe arthritis and who takes nonsteroidal antiinflammatory drugs (NSAIDs) daily develops a duodenal ulcer. The patient has tried a cyclooxygenase-2 selective NSAID in the past and states that it is not as effective as the current NSAID. The primary care nurse practitioner (NP) should: a. change the NSAID to a corticosteroid. b. prescribe omeprazole (Prilosec). c. teach the patient about a bland diet. d. prescribe cimetidine (Tagamet) b. prescribe omeprazole (Prilosec). Patients with NSAID-induced ulcer should discontinue the NSAID if possible and use an acid suppressant. This patient has severe arthritis and so cannot discontinue the NSAID. In a situation such as this, a PPI is indicated. Cimetidine is a histamine-2 blocker, which would be a second-line choice, but cimetidine has many serious side effects. Bland diets are not effective in treating ulcers. Corticosteroids are not indicated. A patient who has stable angina and uses sublingual nitroglycerin tablets is in the clinic and begins having chest pain. The primary care NP administers a nitroglycerin tablet and instructs the patient to lie down. The NP's next action should be to: a. call EMS. b. give 325 mg of chewable aspirin. c. administer oxygen at 2 L/minute. d. obtain an electrocardiogram c. administer oxygen at 2 L/minute. When a patient experiences an acute attack of angina in the clinic, the primary care NP should be prepared to treat the condition. After giving nitroglycerin, oxygen should be administered. An electrocardiogram is not immediately indicated. Chewable aspirin is given if the angina is unrelieved and when the patient is being transported to the hospital. EMS should be activated if there is no pain relief 5 minutes after the first dose of nitroglycerin. A patient who has stable angina is taking nitroglycerin and a b-blocker. The patient tells the primary care NP that the cardiologist is considering adding a calcium channel blocker. The NP should anticipate that the cardiologist will prescribe: a. nicardipine (Cardene). b. nifedipine (Procardia XL). c. isradipine (DynaCirc). d. verapamil HCl (Calan). d. verapamil HCl (Calan). Nitrates and b-blockers are first-line therapy for stable angina. Calcium channel blockers should be reserved for patients who cannot take these agents or patients whose symptoms are not controlled with these agents. Verapamil is one of the calcium channel blockers that should be used. The other calcium channel blockers are not recommended for this purpose. A patient who has stable angina pectoris and a history of previous myocardial infarction takes nitroglycerin and verapamil. The patient asks the primary care nurse practitioner (NP) why it is necessary to take verapamil. The NP should tell the patient that verapamil: a.increases the force of contraction of the cardiac muscle. b. improves blood flow and oxygen delivery to the heart. c.has a positive inotropic effect to increase cardiac output. d. increases the rate of contraction of the cardiac muscle. b. improves blood flow and oxygen delivery to the heart. Verapamil decreases the force of smooth muscle contraction in the smooth muscle of the coronary and peripheral vessels; this results in coronary artery dilation, which lowers coronary resistance and improves blood flow through collateral vessels as well as oxygen delivery to ischemic areas of the heart. Calcium channel blockers do not increase the rate or force of contraction of the heart. A patient who has type 2 diabetes is seen by a primary care NP for a physical examination. The NP notes a blood pressure of 140/95 mm Hg on three occasions. A urinalysis reveals macroalbuminuria. The patient's serum creatinine is 1.9 mg/dL. Adhering to evidence-based practice, the NP should prescribe: a.enalapril maleate (Vasotec). b. losartan (Cozaar). c.captopril (Capoten). d. fosinopril sodium (Monopril). b. losartan (Cozaar). In patients with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency (serum creatinine >1.5 mg/dL), ARBs have been shown to delay the progression of nephropathy. Losartan is an ARB. The other medications are ACE inhibitors. A patient who has type 2 diabetes mellitus will begin taking a bile acid sequestrant. Which bile acid sequestrant should the primary care NP order? a. Colesevelam (Welchol) b.Colestipol (Colestid) c.Cholestyramine (Questran Light) d.Cholestyramine (Questran) a. Colesevelam (Welchol) All bile acid sequestrants are equally effective. Colesevelam has an additional indication to improve glycemic control in adults with type 2 diabetes and so should be selected when prescribing a bile acid sequestrant for this patient. A patient who is about to begin chemotherapy expresses concern to the primary care NP about gastrointestinal side effects of the treatments. The NP should reassure the patient that: a. taking ondansetron before chemotherapy decreases nausea and vomiting. b. most newer chemotherapeutic agents do not cause nausea and vomiting. c. antiemetics will be administered as needed if nausea and vomiting occur. d. a scopolamine patch is an effective way to prevent nausea and vomiting. a. taking ondansetron before chemotherapy decreases nausea and vomiting. In many situations, nausea and vomiting may be anticipated. These situations may involve motion sickness or chemotherapy. Premedicating the patient with an antiemetic may be necessary in order for the patient to receive full therapy; this is the current standard of care. Although most chemotherapeutic agents have emetogenic potential, the use of premedication with 5-HT3 receptor antagonists significantly decreases the nausea and vomiting experienced during and after administration The most common agent in this class, ondansetron, is now available as a generic. A patient who takes nitroglycerin for stable angina pectoris develops hypertension. The primary care NP should contact the patient's cardiologist to discuss adding: a. nifedipine (Procardia XL). b.diltiazem (Cardizem). c.verapamil HCl (Calan). d.amlodipine (Norvasc). a. nifedipine (Procardia XL). Nifedipine and related drugs are potent vasodilators, which makes them more effective for hypertension than verapamil and diltiazem. Amlodipine is not a first-line drug. A patient who takes spironolactone for heart failure has begun taking digoxin (Lanoxin) for atrial fibrillation. The primary care NP provides teaching for this patient and asks the patient to repeat back what has been learned. Which statement by the patient indicates understanding of the teaching? a."I should eat foods high in potassium." b. "I should use a salt substitute while taking these medications." c."I should avoid high-sodium foods." d. "I need to take a calcium supplement every day." c. "I should avoid high-sodium foods." Patients should be taught to reduce their overall sodium intake by avoiding salty foods and not adding salt while cooking. Spironolactone is a potassium-sparing diuretic and carries a risk of hyperkalemia, which can make the myocardium more sensitive to the effects of digoxin. Hypercalcemia can predispose the patient to digoxin toxicity. Salt substitutes are high in potassium. A patient who was recently diagnosed with COPD comes to the clinic for a follow-up evaluation after beginning therapy with a SABA as needed for dyspnea. The patient reports occasional mild exertional dyspnea but is able to sleep well. The patient's FEV1 in the clinic is 85% of predicted, and oxygen saturation is 96%. The primary care NP should recommend: a.a combination LABA/ICS twice daily. b. home oxygen therapy as needed for dyspnea. c.influenza and pneumococcal vaccines. d. ipratropium bromide (Atrovent) twice daily. c. influenza and pneumococcal vaccines. Influenza and pneumococcal immunizations are recommended to help reduce comorbidity that will affect respiratory status. This patient is stable with the prescribed medications, so no additional medications are needed at this time. Home oxygen therapy is used for patients with severe resting hypoxemia. A patient who will begin using nitroglycerin for angina asks the primary care NP how the medication works to relieve pain. The NP should tell the patient that nitroglycerin acts to: a. prevent catecholamine release. b. reduce C-reactive protein levels. c.dissolve atheromatous lesions. d. relax vascular smooth muscle. d. relax vascular smooth muscle. Nitrates relax vascular smooth muscle via stimulation of intracellular cyclic guanosine monophosphate production with the major effect being to reduce myocardial oxygen demand. Nitrates do not dissolve atheromatous lesions, prevent catecholamine release, or reduce C- reactive protein levels. A patient who will undergo surgery in implant a biosynthetic heart valve asks the primary care NP whether any medications will be necessary postoperatively. The NP should tell the patient that it will be necessary to take: a.lifelong warfarin combined with enoxaparin as needed. b. warfarin for 3 months postoperatively plus long-term aspirin. c.heparin injections as needed based on activated partial thromboplastin time levels. d. daily low-dose aspirin for 1 year. b. warfarin for 3 months postoperatively plus long-term aspirin. Patients with biosynthetic valves should receive anticoagulation for 3 months with long-term aspirin prophylaxis. Patients with biosynthetic valves should receive anticoagulation for 3 months (INR goal, 2 to 3). Long-term prophylaxis for these patients should include aminosalicylic acid (75 to 100 mg daily), unless AF is present. A patient with a diagnosis of peptic ulcer disease asks the primary care NP about nonpharmacologic treatment. Which statement by the NP is correct? a. "Lifestyle changes and proper diet may eliminate the need for medication." b. "You should consume a diet that is high in fiber." c. "One or two cups of coffee each day won't hurt you." d. "Alcoholic beverages are strictly prohibited when you have an ulcer." b. "You should consume a diet that is high in fiber." Balanced meals consumed at regular times that are high in fiber are encouraged. Caffeine increases acid secretion and should be avoided. Patients may consume alcohol in moderation. Although lifestyle changes and proper diet are an integral part of treatment for peptic ulcer disease, they do not eliminate the need for medications. A patient with a history of coronary heart disease develops atrial fibrillation. The primary care NP refers the patient to a cardiologist who performs direct current cardioversion. The NP should expect the patient to begin taking which b-blocker medication? a. Propranolol (Inderal) b. Nadolol (Corgard) c. Sotalol (Betapace) d. Timolol (Blocadren) c. Sotalol (Betapace) Sotalol is classified as a class II and III antiarrhythmic and is a preferred agent in patients with a history of coronary heart disease. A patient with a previous history of myocardial infarction (MI) who takes nitroglycerin for angina develops hypertension. The primary care NP is considering ordering an ACE inhibitor. Preliminary laboratory tests reveal decreased renal function. The NP should: a.begin therapy with a low-dose ACE inhibitor. b. add a low-dose thiazide diuretic to the drug regimen. c.choose an ARB instead. d. order a renal perfusion study before starting treatment. d. order a renal perfusion study before starting treatment. ACE inhibitors are contraindicated in patients with bilateral renal stenosis. Because this patient has decreased renal function, perfusion studies are indicated. If the patient does not have bilateral renal stenosis, a low-dose ACE inhibitor may be used. An ARB is indicated if perfusion studies show bilateral renal stenosis. A thiazide diuretic is not indicated. A patient with asthma is given an asthma action plan and returns to the clinic in 2 weeks to follow up on symptoms. Which statement by the patient indicates a need for further teaching? a."I should rinse my mouth thoroughly after using an ICS." b. "A side effect of albuterol may be shortness of breath." c."I use the ICS as needed when I am wheezing." d. "I put the albuterol metered-dose inhaler in my mouth with my lips sealed around it." c. "I use the ICS as needed when I am wheezing." ICSs are controller medications and are not used as needed for symptoms, so this statement by the patient indicates a need for further teaching. The other statements are true. A patient with erosive esophagitis is taking lansoprazole (Prevacid). The primary care NP performs a medication history and learns that the patient also takes digoxin. The NP should recommend: a. decreasing the dose of digoxin. b. obtaining a serum digoxin level. c. changing the PPI to omeprazole. d. increasing the dose of lansoprazole. b. obtaining a serum digoxin level. Because PPIs decrease gastric acid, they may interfere with the absorption of drugs that require absorption in an acid stomach, including digoxin. It may be necessary to increase the dose of digoxin but not before obtaining a serum digoxin level. All PPIs have this effect, so changing to another PPI would not solve the problem. Increasing the dose of lansoprazole would decrease the absorption of digoxin. A patient with peptic ulcer disease is taking a histamine-2 blocker and tells the primary care NP that over-the-counter antacid tablets help with the discomfort. The NP should tell this patient to: a.take the antacid and the histamine-2 blocker at the same time b. take the histamine-2 blocker 2 hours before taking the antacid. c.discontinue the histamine-2 blocker. d. discontinue the antacid. b. take the histamine-2 blocker 2 hours before taking the antacid. Histamine-2 blockers should not be taken within 2 hours of antacid ingestion because antacids decrease the action of histamine-2 blockers. A patient with primary hypercholesterolemia is taking an HMG- CoA reductase inhibitor. All of the patient's baseline LFTs were normal. At a 6-month follow-up visit, the patient reports occasional headache. A lipid profile reveals a decrease of 20% in the patient's LDL cholesterol. The NP should: a.reassure the patient that this side effect is common. b. order CK-MM tests. c.order LFTs. d. consider decreasing the dose of the medication. a. reassure the patient that this side effect is common. LFTs should be performed at baseline, 12 weeks after initiation of therapy, and only periodically thereafter. Headaches are common side effects, but do not raise concern about hepatotoxicity. CK-MM tests are indicated if patients report muscle pain or weakness. It is not necessary to decrease the medication. Persistent atrial fibrillation (AF) is diagnosed in a patient who has valvular disease, and the cardiologist has prescribed warfarin (Coumadin). The patient is scheduled for electrical cardioversion in 3 weeks. The patient asks the primary care nurse practitioner (NP) why the procedure is necessary. The NP should tell the patient: a. if the medication proves effective, the procedure may be canceled. b. there are no medications that alter the arrhythmia causing AF. c. this medication prevents clots but does not alter rhythm. d. to ask the cardiologist if verapamil may be ordered instead of cardioversion. c. this medication prevents clots but does not alter rhythm. Persistent AF lasts longer than 7 days and episodes fail to terminate on their own, but episodes can be terminated by electrical cardioversion after therapeutic warfarin therapy for 3 weeks. Warfarin does not alter AF. b-Blockers, calcium channel blockers, and digoxin are sometimes given to alter the rate. Verapamil is not an alternative to cardioversion for patients with persistent AF. A postmenopausal woman develops NSAID-induced ulcer. The primary care NP should prescribe: a. pantoprazole (Protonix). b. omeprazole (Prilosec). c. esomeprazole (Nexium). d. ranitidine (Zantac). d. ranitidine (Zantac). PPIs carry a possible increased risk of fractures in postmenopausal women. The NP should begin therapy with a histamine-2 blocker, such as ranitidine. The primary care NP is considering prescribing captopril (Capoten) for a patient. The NP learns that the patient has decreased renal function and has renal artery stenosis in the right kidney. The NP should: a.initiate ACE inhibitor therapy at a low dose. b. order lisinopril (Zestril) instead of captopril to avoid increased nephropathy. c.consider a different drug class to treat this patient's symptoms. d. give the captopril with a thiazide diuretic to improve renal function. a. initiate ACE inhibitor therapy at a low dose. Patients with impaired renal function should use low-dose ACE inhibitors. It is not necessary to avoid ACE inhibitors with unilateral renal stenosis. The primary care NP sees a new African-American patient who has blood pressure readings of 140/90 mm Hg, 130/85 mm Hg, and 142/80 mm Hg on three separate occasions. The NP learns that the patient has a family history of hypertension. The NP should: a.prescribe a thiazide diuretic and an angiotensin- converting enzyme inhibitor. b. discuss dietary and lifestyle modifications with the patient. c.initiate monotherapy with a thiazide diuretic. d. begin combination therapy with an ARB and a calcium- channel blocker. c. initiate monotherapy with a thiazide diuretic. African Americans tend to respond better than whites to diuretic monotherapy, so this is an appropriate starting therapy. Calcium-channel blockers and ARBs are preferred as adjunct medications in African Americans. The primary care NP sees a new patient for a routine physical examination. When auscultating the heart, the NP notes a heart rate of 78 beats per minute with occasional extra beats followed by a pause. History reveals no past cardiovascular disease, but the patient reports occasional syncope and shortness of breath. The NP should: a.order a complete blood count (CBC) and electrolytes and consider a trial of procainamide. b. prescribe a b-blocker and anticoagulant and order 24-hour Holter monitoring. c. schedule a cardiac stress test and a graded exercise test. d. order an ECG and refer to a cardiologist. d. order an ECG and refer to a cardiologist. Premature ventricular contractions are premature ventricular beats with a compensatory pause. This patient has no prior history, but does have syncope and shortness of breath. The NP should order an ECG and refer the patient to a cardiologist for further evaluation. If there were no other symptoms, the NP could order stress testing. Medications are not indicated without further testing and without consultation with a cardiologist. The primary care NP sees a new patient who has diabetes and hypertension and has been taking a thiazide diuretic for 6 months. The patient's blood pressure at the beginning of treatment was 150/95 mm Hg. The blood pressure today is 138/85 mm Hg. The NP should: a.add an angiotensin-converting enzyme inhibitor. b. change to an aldosterone antagonist medication. c.continue the current drug regimen. d. order a b-blocker. a. add an angiotensin-converting enzyme inhibitor. Evidence-based guidelines suggest that optimal control of hypertension to less than 130/80 mm Hg could prevent 37% of cardiovascular disease in men and 56% in women, so this patient, although showing improvement, could benefit from the addition of another medication. An angiotensin-converting enzyme inhibitor is an appropriate drug for patients who also have diabetes. b-Blockers and aldosterone antagonist medications are not recommended for patients with diabetes. A primary care NP sees a patient 2 days after an outpatient surgical procedure. The patient reports using ondansetron for nausea. The NP notes a blood pressure of 88/56 mm Hg, and the patient reports feeling faint. The NP should suspect: a.hemorrhage b. drug toxicity. c. drug interaction. d. dehydration. b. drug toxicity Hypotension and faintness are signs of overdose of ondansetron, and drug toxicity is the more likely cause of this patient's decrease in blood pressure. A primary care NP sees a patient who is about to take a cruise and reports having had motion sickness with nausea on a previous cruise. The NP prescribes the scopolamine transdermal patch and should instruct the patient to apply the patch: a.every 3 days. b. daily. c.1 hour before embarking. d. as needed for nausea. a. every 3 days. The transdermal system allows steady-state plasma levels of scopolamine to be reached rapidly and maintained for 3 days. The onset of action is approximately 4 hours. The patch should be changed every 3 days and left on at all times, not as needed. A primary care NP sees a patient who is being treated for heart failure with digoxin, a loop diuretic, and an ACE inhibitor. The patient reports having nausea. The NP notes a heart rate of 60 beats per minute and a blood pressure of 100/60 mm Hg. The NP should: a.decrease the dose of the diuretic to prevent further dehydration. b. obtain a serum potassium level to assess for hyperkalemia. c. obtain a digoxin level before the patient takes the next dose of digoxin. d. hold the ACE inhibitor until the patient's blood pressure stabilizes. c. obtain a digoxin level before the patient takes the next dose of digoxin. To monitor for toxicity, the health care provider must be alert to early signs of toxicity and must obtain a serum level. Nausea is an early sign of toxicity. A primary care NP sees a patient who reports having decreased frequency of stools over the past few months. In the clinic today, the patient has severe abdominal cramping and an abdominal radiograph shows an increased stool load in the sigmoid colon and rectum. The NP should: a. recommend polyethylene glycol (MiraLAX) and 2000 mL of fluid daily. b. start daily methylcellulose (Citrucel) and increased fluids. c. order a sodium phosphate enema and psyllium (Metamucil). d. give magnesium hydroxide (Milk of Magnesia). c. order a sodium phosphate enema and psyllium (Metamucil). If a patient is severely constipated, an enema is indicated. When there is underlying chronic constipation, long-term management may be necessary. Bulk laxatives, such as psyllium, are first-line treatments for long-term constipation. A primary care nurse practitioner (NP) is evaluating a patient with asthma who reports having wheezing and coughing 1 or 2 days each week and awakening from sleep three or four times each month with asthma symptoms. The patient's forced expiratory volume in 1 second (FEV1) is 80% of the predicted value. The patient's current medication regimen is an albuterol metered-dose inhaler, 2 puffs every 4 hours as needed. The NP should prescribe: a. a long-acting b-adrenergic agonist (LABA), 1 puff bid. b. a low-dose inhaled corticosteroid (ICS), 2 puffs bid. c. montelukast (Singulair) po daily. d. ipratropium bromide bid with albuterol. b. a low-dose inhaled corticosteroid (ICS), 2 puffs bid. This patient has symptoms of mild, persistent asthma. The preferred controller medication in adults and children with persistent asthma is a low-dose ICS. Montelukast is a leukotriene modifier, which may be considered as an alternative to a low- dose ICS but is not the first option to try. Ipratropium is often used during an acute exacerbation but not for long-term control. LABA medications are used in patients with moderate persistent symptoms. The primary care nurse practitioner (NP) sees a patient for a physical examination and orders laboratory tests that reveal low- density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30 mg/dL, and triglycerides of 350 mg/dL. The patient has no previous history of coronary heart disease. The NP should consider prescribing: a.nicotinic acid (Niaspan). b. gemfibrozil (Lopid). c.simvastatin (Zocor). d. ezetimibe (Zetia). b. gemfibrozil (Lopid). Fibric acid derivatives, such as gemfibrozil, are indicated for reducing the risk that coronary heart disease may develop in patients without a history of coronary heart disease who have low HDL cholesterol levels and elevated triglyceride levels. This patient's LDL is within normal limits, so a 3- hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, such as simvastatin, is not indicated. Ezetimibe is a selective cholesterol absorption inhibitor, used to reduce total and LDL cholesterol. Nicotinic acid is used to treat hyperlipidemia in patients who have failed dietary therapy. The primary care nurse practitioner (NP) sees a patient in the clinic who has a blood pressure of 130/85 mm Hg. The patient's laboratory tests reveal high-density lipoprotein, 35 mg/dL; triglycerides, 120 mg/dL; and fasting plasma glucose, 100 mg/dL. The NP calculates a body mass index of 29. The patient has a positive family history for cardiovascular disease. The NP should: a.prescribe a thiazide diuretic. b. reassure the patient that these findings are normal. c.counsel the patient about dietary and lifestyle changes. d. consider treatment with an angiotensin-converting enzyme inhibitor. c. counsel the patient about dietary and lifestyle changes. The patient's blood pressure indicates prehypertension, but the patient does not have cardiovascular risk factors such as hyperlipidemia or hyperinsulinemia. The body mass index indicates that the patient is overweight but not obese. Pharmacologic treatment is not recommended for prehypertension unless compelling reasons are present. The findings are not normal, so it is appropriate to counsel the patient about diet and exercise. A primary care nurse practitioner (NP) sees a patient who is concerned about constipation. The NP learns that the patient has three to four bowel movements per week with occasional hard stools but no straining with defecation. The NP should recommend: a. increased intake of fluids and fiber. b. docusate sodium (Colace) as needed. c. psyllium (Metamucil) on a daily basis. d. polyethylene glycol (MiraLAX) as needed. a. increased intake of fluids and fiber. The objective definition of constipation is two or fewer bowel movements per week or excessive straining. This patient does not meet these criteria, so the NP should recommend increasing fluids and fiber to help soften stools. Laxatives should not be used unless constipation is present or is chronic to avoid laxative dependence. A woman has severe IBS and takes hyoscyamine sulfate (Levsin), simethicone (Phazyme), and a TCA. She reports having continued severe diarrhea. The primary care NP should: a.refer her to a gastroenterologist for endoscopy. b. increase the fiber in her diet to 30 g per day. c.order diphenoxylate (Lomotil). d. prescribe alosetron after ruling out pregnancy. a. refer her to a gastroenterologist for endoscopy. Alosetron is given only to women with severe chronic diarrhea-predominant IBS and only after anatomic or biochemical abnormalities of the GI tract have been excluded. Because this woman's symptoms are persistent and severe, diphenoxylate and increased dietary fiber are not indicated. A woman is in her first trimester of pregnancy. She tells the primary care nurse practitioner (NP) that she continues to have severe morning sickness on a daily basis. The NP notes a weight loss of 1 pound from her previous visit 2 weeks prior. The NP should consult an obstetrician and prescribe: a. prochlorperazine (Compazine). b. scopolamine transdermal. c. aprepitant (Emend). d. ondansetron (Zofran). d. ondansetron (Zofran). No antiemetic drugs should be used for nausea and vomiting during pregnancy unless approved by an obstetrician. Ondansetron has been shown to be safe and effective (off- label) for hyperemesis gravidum. A woman who is 4 months pregnant comes to the clinic with acute diarrhea and nausea. Her husband is experiencing similar symptoms. The primary care nurse practitioner (NP) notes a temperature of 38.5° C, a heart rate of 92 beats per minute, and a blood pressure of 100/60 mm Hg. The NP should: a. prescribe attapulgite to treat her diarrhea. b. obtain a stool culture and start antibiotic therapy. c. refer her to an emergency department for intravenous (IV) fluids. d. instruct her to replace lost fluids by drinking Pedialyte. c. refer her to an emergency department for intravenous (IV) fluids. Diarrhea in pregnant women can have serious consequences, and the patient may need to be referred. This woman is showing signs of dehydration and needs IV rehydration. Attapulgite is a category B drug for pregnancy and should be avoided if possible. Acute diarrhea is usually viral, and antibiotics are not given unless a stool culture is performed and is positive. Because the patient is pregnant and has nausea, oral rehydration would not be effective. A woman with IBS has been taking antispasmodic medications and reports some relief, but she tells the primary care NP that the disease is interfering with her ability to work because of increased pain. The NP should consider prescribing: a. alosetron (Lotronex). b. misoprostol (Cytotec). c. simethicone (Phazyme). d. tricyclic antidepressants (TCAs). d. tricyclic antidepressants (TCAs). TCAs and selective serotonin reuptake inhibitors (SSRIs) have been shown to reduce symptoms and are useful for long-term treatment. Alosetron is ordered by a GI specialist if symptoms are resistant to all other interventions and has been shown to be effective in women with diarrhea-predominant IBS. Misoprostol is used to treat NSAID-induced ulcers. Simethicone acts locally to treat symptoms of trapped air and gas.